"We think that better control of the diabetes should improve both the process and the outcomes of care."

How many computers does it take to check your glucose level?

Though it may sound like the start of a stand-up routine, computers are taking a more and more active role in the daily management of health care. Take a new $28 million project called Informatics for Diabetes Education and Telemedicine (IDEATel) slated to begin this fall, for example.

Doctors at Columbia University in New York and the Joslin Diabetes Center of SUNY Upstate Medical University have teamed up to prove that the consistent care that telemedicine offers can provide tangible benefits to all patients with diabetes.

And they are starting with patients who have the most to gain. IDEATel will provide 750 rural and inner-city diabetics with all the tools  computers, internet access, blood pressure cuffs, finger stick glucometers and medical monitoring  they need to have "electronic house calls". Patients will download data directly from their computers and email it to doctors and nurses capable of monitoring their progress remotely. In limited cases, digital photography will be used to monitor eyesight as well as foot and hand skin conditions, all of which are critical areas for people managing diabetes.

In return, patients will receive instructional email messages from trained nurses who can mark their progress and modify behavior or medications as needed.

Why download disease?

The idea behind IDEATel is to show that technology can improve outcomes for patients traditionally at risk for complications, according to Steven Shea, M.D., supervisor of IDEATel and professor of medicine in public health at Columbia University. Dr. Shea believes that the project will not only be beneficial for these underserved patients, it will help prove telemedicine's legitimacy.

"Diabetes is a good challenge for this technology," Dr. Shea says. "It's a condition where patients need to care for themselves every day in their homes. We think that better control of the diabetes should improve both the process and the outcomes of care."

Still, Dr. Shea cautions that "electronic house calls" are not meant to replace regular, in-person contact with doctors. "There are some things you have to go to the doctor's office to do," he says, citing examinations and specific screenings as examples. "This isn't a substitute for that."

According to Dr. Shea and others, patients see more than physical benefits to traditional doctors' office visits. "Some people need the face-to-face contact with the doctor in order to follow their self-care directions," says Marilyn Clements, who was diagnosed with Type 2 diabetes three years ago. "Doing it via electronics might make it too impersonal."

Dr. Shea, however, points out that telemedicine provides a level of continuous care that regular, episodic trips to the doctor's office cannot. Those not used to daily care, like those targeted by IDEATel, can be encouraged by immediate feedback when they check their email. Knowing that their daily progress is being monitored by health professionals could encourage patients to follow diet and behavior plans, like eating regular meals and quitting smoking. Daily glucose level records can also alert doctors to unhealthy swings that might not be obvious in office visits.

For now, Dr. Shea says, the biggest drawback to telemedical care is its high cost. But he hopes to prove otherwise. The initial high cost of telemedicine may be offset by the long-run savings when patients stay healthier. According to Dr. Shea, if successful, telemedicine could shave hundreds of millions of dollars off the annual $45 billion cost of complications from diabetes. In part for these reasons, one of IDEATels goals is to show that this technology should be considered a reimbursable expense from insurance companies.

Trusting the technology

While many patients are anxious to participate in IDEATel, Dr. Shea says that telemedicine's future depends largely on maintaining not only informational accuracy, but also patient trust. If IDEATel meets its goals, Dr. Shea hopes that Internet technology can become a regular component of care for many diseases, not just diabetes.

"For a chronic condition, the key is to help empower patients to take better care of themselves day to day, moment to moment," Dr. Shea says. "The goal is to give them as much power over their own care as possible."

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